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Meta-Analysis
. 2012 Feb 15;2012(2):CD009663.
doi: 10.1002/14651858.CD009663.

Sumatriptan (intranasal route of administration) for acute migraine attacks in adults

Christopher J Derry  1 , Sheena Derry, R Andrew Moore
Affiliations
Meta-Analysis

Sumatriptan (intranasal route of administration) for acute migraine attacks in adults

Christopher J Derry et al. Cochrane Database Syst Rev. .

Abstract

Background: Migraine is a highly disabling condition for the individual and also has wide-reaching implications for society, healthcare services, and the economy. Sumatriptan is an abortive medication for migraine attacks, belonging to the triptan family. Intranasal administration may be preferable to oral for individuals experiencing nausea and/or vomiting, although it is primarily absorbed in the gut, not the nasal mucosa.

Objectives: To determine the efficacy and tolerability of intranasal sumatriptan compared to placebo and other active interventions in the treatment of acute migraine attacks in adults.

Search methods: We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, online databases, and reference lists for studies through 13 October 2011.

Selection criteria: We included randomised, double-blind, placebo- and/or active-controlled studies using intranasal sumatriptan to treat a migraine headache episode, with at least 10 participants per treatment arm.

Data collection and analysis: Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate relative risk (or 'risk ratio') and numbers needed to treat to benefit (NNT) or harm (NNH) compared to placebo or a different active treatment.

Main results: Twelve studies (4755 participants) compared intranasal sumatriptan with placebo or an active comparator. Most of the data were for the 10 mg and 20 mg doses. Sumatriptan surpassed placebo for all efficacy outcomes. For sumatriptan 10 mg versus placebo the NNTs were 7.3, 7.4, and 5.5 for pain-free at two hours, and headache relief at one and two hours, respectively. For sumatriptan 20 mg versus placebo the NNTs were 4.7, 4.9, and 3.5, respectively, for the same outcomes. The 20 mg dose was significantly better than the 10 mg dose for each of these three primary efficacy outcomes.Relief of headache-associated symptoms, including nausea, photophobia, and phonophobia, was greater with sumatriptan than with placebo, and use of rescue medication was lower with sumatriptan than placebo. For the most part, adverse events were transient and mild and were more common with sumatriptan than placebo.Direct comparison of sumatriptan with active treatments was limited to two studies, one comparing sumatriptan 20 mg and dihydroergotamine (DHE) 1 mg, and one comparing sumatriptan 20 mg with rizatriptan 10 mg.

Authors' conclusions: Intranasal sumatriptan is effective as an abortive treatment for acute migraine attacks, relieving pain, nausea, photophobia, phonophobia, and functional disability, but is associated with increased adverse events compared with placebo.

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Conflict of interest statement

RAM and SD have received research support from charities, government, and industry sources at various times. RAM has consulted for various pharmaceutical companies, including GlaxoSmithKline, the manufacturers of sumatriptan. RAM has received lecture fees from pharmaceutical companies related to analgesics and other healthcare interventions. GlaxoSmithKline were not in any way involved in this review.

Figures

1
1
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
2
2
Forest plot of comparison: 3 Sumatriptan nasal spray 20 mg versus placebo, outcome: 3.1 Pain‐free at 2 h.
3
3
Forest plot of comparison: 3 Sumatriptan nasal spray 20 mg versus placebo, outcome: 3.4 Headache relief at 2 h.
4
4
Forest plot of comparison: 3 Sumatriptan nasal spray 20 mg versus placebo, outcome: 3.8 Any adverse event within 24 h.
5
5
L'Abbé plot showing results for sumatriptan 20 mg versus placebo for pain‐free at two hours. Each circle represents a different study; size of circle is proportional to size of study; diagonal is line of equivalence
6
6
L'Abbé plot showing results for sumatriptan 20 mg versus placebo for headache relief at one hour. Each circle represents a different study; size of circle is proportional to size of study; diagonal is line of equivalence
7
7
L'Abbé plot showing results for sumatriptan 20 mg versus placebo for headache relief at two hours. Each circle represents a different study; size of circle is proportional to size of study; diagonal is line of equivalence
1.1
1.1. Analysis
Comparison 1 Sumatriptan nasal spray 5 mg versus placebo, Outcome 1 Headache relief at 1 h.
1.2
1.2. Analysis
Comparison 1 Sumatriptan nasal spray 5 mg versus placebo, Outcome 2 Headache relief at 2 h.
1.3
1.3. Analysis
Comparison 1 Sumatriptan nasal spray 5 mg versus placebo, Outcome 3 Relief of associated symptoms.
1.4
1.4. Analysis
Comparison 1 Sumatriptan nasal spray 5 mg versus placebo, Outcome 4 Individual adverse events.
2.1
2.1. Analysis
Comparison 2 Sumatriptan nasal spray 10 mg versus placebo, Outcome 1 Pain‐free at 2 h.
2.2
2.2. Analysis
Comparison 2 Sumatriptan nasal spray 10 mg versus placebo, Outcome 2 Headache relief at 1 h.
2.3
2.3. Analysis
Comparison 2 Sumatriptan nasal spray 10 mg versus placebo, Outcome 3 Headache relief at 2 h.
2.4
2.4. Analysis
Comparison 2 Sumatriptan nasal spray 10 mg versus placebo, Outcome 4 Use of rescue medication within 24 h.
2.5
2.5. Analysis
Comparison 2 Sumatriptan nasal spray 10 mg versus placebo, Outcome 5 Relief of associated symptoms.
2.6
2.6. Analysis
Comparison 2 Sumatriptan nasal spray 10 mg versus placebo, Outcome 6 Relief of functional disability at 2 h.
2.7
2.7. Analysis
Comparison 2 Sumatriptan nasal spray 10 mg versus placebo, Outcome 7 Individual adverse events.
3.1
3.1. Analysis
Comparison 3 Sumatriptan nasal spray 20 mg versus placebo, Outcome 1 Pain‐free at 2 h.
3.2
3.2. Analysis
Comparison 3 Sumatriptan nasal spray 20 mg versus placebo, Outcome 2 Pain‐free at 1 h.
3.3
3.3. Analysis
Comparison 3 Sumatriptan nasal spray 20 mg versus placebo, Outcome 3 Headache relief at 1 h.
3.4
3.4. Analysis
Comparison 3 Sumatriptan nasal spray 20 mg versus placebo, Outcome 4 Headache relief at 2 h.
3.5
3.5. Analysis
Comparison 3 Sumatriptan nasal spray 20 mg versus placebo, Outcome 5 Use of rescue medication within 24 h.
3.6
3.6. Analysis
Comparison 3 Sumatriptan nasal spray 20 mg versus placebo, Outcome 6 Relief of associated symptoms.
3.7
3.7. Analysis
Comparison 3 Sumatriptan nasal spray 20 mg versus placebo, Outcome 7 Relief of functional disability at 2 h.
3.8
3.8. Analysis
Comparison 3 Sumatriptan nasal spray 20 mg versus placebo, Outcome 8 Any adverse event within 24 h.
3.9
3.9. Analysis
Comparison 3 Sumatriptan nasal spray 20 mg versus placebo, Outcome 9 Individual adverse events.
4.1
4.1. Analysis
Comparison 4 Sumatriptan nasal spray 40 mg versus placebo, Outcome 1 Headache relief at 1 h.
4.2
4.2. Analysis
Comparison 4 Sumatriptan nasal spray 40 mg versus placebo, Outcome 2 Headache relief at 2 h.
See this image and copyright information in PMC

References

References to studies included in this review

Boureau 2000 {published data only}
    1. Glaxo Study No. S2B‐T60. Cited in Dahlöf 1999, Table 1. Reference given as "Glaxo Study No. S2B‐T60. Data on file with Glaxo Wellcome Research and Development".
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    1. Becker WJ. Glaxo Study No. S2B‐T47. Cited in Dahlöf 1999, Table 1. Reference given as "Becker WJ, on behalf of the study group. A placebo‐controlled, dose‐defining study of sumatriptan nasal spray in the acute treatment of migraine. In: Olesen J, Tfelt‐Hansen P, editors. Headache treatment: trial methodology and new drugs. Philadelphia: Lippincott‐Raven, 1997".
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S2BT50 {unpublished data only}
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Salonen 1991 {published data only}
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Salonen 1994 {published data only}
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SUM40031 {unpublished data only}
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Wang 2007 {published data only}
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References to studies excluded from this review

S2CM12 {unpublished data only}
    1. Glaxo Study No. S2CM12. Cited in Dahlöf 1999, Table 1. Reference given as "Glaxo Study No. S2CM12. Data on file with Glaxo Wellcome Research and Development".

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